2023 Leadership and Excellence Nomination Form

Award Designation

Nominator Information

The completed nomination form and the nominee's curri3ulum vitae must be submitted electronically no later than March 15, 2023 to be considered by the Awards Committee. Up to three letters of support for the nomination may also be submitted. Letter of support are greatly encouraged and are at the discretion of the nominator. The letters of support should explain why the nominee merits the award and specifically relate the nominee's background to the award criteria. Please also submit any letters of support in Word format.

Receipt of each nomination will be confirmed by e-mail. Please follow up with Mary Ellen Fletcher if you do not receive a confirmation.

Nominated by

Date submitted

Street address

City

State

Zip

Email address

Signature

By typing your name and checking the following button, you are agreeing that this is your electronic signature.

Yes

Chapter endorsement

Yes

Nominee

Name of nominee

Telephone

Street address

City

State

Zip

Please state why this person should be honored with this award, based on criteria indicated in the Awards brochure:

ACEP office held (national and chapter)

Committees (National, Local/Name of Committee and Length of Service):

Other Emergency Medicine-Related Services (Title and Length of Service)

Other Activities of Special Merit (Civic, Institution, etc.)

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File types accepted: PDF, DOC, DOCX, TXT, RTF, JPG (JPEG), PNG, TIFF, EPS.

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